Fourth-year interns at Bastyr University are actively developing their clinical skills through treating patients at the school's clinic. They engage their didactic skills in rigorous case taking, examinations, evaluation, and a naturopathic-focused treatment plan under the supervision of their attending doctor. The interns are able to gain experience in areas such as mental health, mind-body medicine, oncology, hydrotherapy, physical medicine, out-reach community care, IV treatment, biofeedback, and so on. Each one of these opportunities presents a prime opportunity for the students to enrich their knowledge about conditions and approaches to care. In efforts to salient their understanding, the students write case reports under the supervision of Dr. Baljit Khamba in their course "Advanced Case Studies." By completing these reports, future practitioners gain a valuable skill that they can then utilize once they graduate.

Abstract
Ankylosing spondylitis (AS) is a type of inflammatory arthritis that affects the spine. It is a very rare disease that causes inflammation of the spinal joints leading to severe, chronic pain. The hallmark feature of AS is the involvement of the sacroiliac joints during the progression of the disease. We will investigate treatments for autoimmune conditions, specifically related to ankylosing spondylitis.

Vitamin D plays an important role in autoimmunity since there is a correlation between vitamin D deficiency and an increased risk for autoimmunity. Being deficient in vitamin D is a global epidemic that has been linked to numerous diseases. Vitamin D is an endocrine hormone known for its important role in regulating calcium and phosphorus metabolism as well as proper bone formation. Nevertheless, vitamin D is a vital modulator of our immune system. Vitamin D deficiency has been associated with increased risk of cancer, diabetes, and cardiovascular disease.

Is vitamin D an effective treatment for autoimmune diseases? Given the research, there appears to be a significant correlation between vitamin D deficiency and an increased risk of autoimmunity. Increasing this patient's serum vitamin D levels correlates with her overall improvement. Ultimately, the need for increased research interest on the role of vitamin D in autoimmune disease is warranted.

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Introduction
Although the exact cause of AS is unknown, researchers believe that genetics play a key role in this disease. Around ninety percent of individuals with AS have a genetic marker called HLA-B27. This gene, however, does not need to be positive to have AS. Analogously, one who has this genetic marker, may not develop AS during their lifetime. Researchers believe that this genetic marker might have an influence on one's microbiome. There is a strong association with intestinal dysbiosis and AS patients.

Scientists suspect that other genes along with a triggering environmental exposure such as an infection are necessary to activate AS in susceptible people. Researchers have found over sixty genes that are associated with this disease such as ERAP 1, IL-12, IL-17, and IL-23. Scientists also have found that complications of autoimmune patients stem from the gastrointestinal system when the defense mechanisms and barriers of the intestines are disrupted, allowing bacteria to pass through the bloodstream. This immune dysregulation leads to changes in the microbiome, resulting in alterations in the immune response. Microbial peptides trigger HLA-B27 to start an autoimmune response through molecular mimicry. Inflammation eventually leads to triggering new bone formation and fusion of spinal joints.

Ankylosing spondylitis is diagnosed under these parameters: pain persisting for more than three months, back pain with stiffness that worsens with immobility and that occurs especially at night and early morning.The onset of this disease usually begins under forty-five years of age. Upon physical examination, there will be inflammation and pain along the back, pelvic bones, sacroiliac joints, chest, and heels. There can also be decreased spinal mobility in all directions and chest expansion restriction.

Case Description
A.Z, a 20-year-old Hispanic female, presented to Bastyr University Clinic in San Diego seeking treatment for her diagnosis of ankylosing spondylitis. Her chief complaints of sacroiliac pain, joint pain, fatigue, insomnia, anxiety, and depression have significantly impacted her quality of life. She was diagnosed in 2016 with being HLA-B27 positive. Imaging revealed inflammation, but no spinal fusion. Her MRI without contrast showed mild erosions of the upper aspect ofthe left sacroiliac joint, associated with patchy bone marrow edema involving both the adjacent sacrum and iliac wing. There was small joint effusion with no osteonecrosis present. Pain is better with movement, worse in the morning and night. Starting at our clinic, her pain was 7/10 persistent pain (10/10 being extreme pain, needing to present to emergency room), with 9/10 severe pain on occasions.

Objective
Her review of systems is positive for fatigue, palpitations, constipation, muscle pain, joint pain, stiffness, back pain, dizziness, nervousness, anxiety, and full of despair. Her family history is pertinent for arthritis, anxiety, hypertension, heart failure, Alzheimer's disease, COPD, diabetes, thyroid disease, and cancer. On physical examination, her blood pressure was 100/58, pulse 85 bpm, respiratory rate 14 bpm, oxygen saturation of 98%, weight: 125.5 lbs, height 5 feet 6 inches, and BMI: 20.21. Patient was in no apparent distress and dressed appropriately for time and place. Her head is normocephalic; atraumatic, slightly tachycardia. All lung fields clear to auscultation with effort and breath sounds normal. Abdominal exam revealed bowel sounds in all four quadrants with no tenderness or masses on light and deep palpitation. No hepatosplenomegaly was present. Positive for back and joint pain, with swelling and pain on palpation on left iliosacral junction.

Her labs were positive for ANA, MTHFR A1298C heterozygous genotype mutation. Her homocysteine is slightly elevated, high globulin, elevated liver enzymes, and low vitamin D levels. Her stool analysis reports high beta glucuronidase and high E. coli with low diversity of bacteria in her stool. Since then, her liver enzymes have normalized, sufficient vitamin D levels, and her non-specific inflammatory markers such as CRP and ESR have decreased.

From the patient's timeline, she has been exposed to many viruses and bacteria throughout her life. She has taken numerous rounds of antibiotics and medications. This is shown through her gastrointestinal dysbiosis. The root cause of many imbalances can be healed by fixing digestive dysfunction. Our ideal focus for her is to heal her gastrointestinal system as well as control and manage her pain since that is affecting her quality of life.

We also recommended increasing acupuncture from every other week to every week since it seems to be benefiting her and helping with her inflammatory flare-ups. The supplements that have most benefited her and notably made the most difference with pain relief were vitamin D, omega-3, and Boswellia extract. We also gave her a support network to connect with others that are in similar situations. In addition, since there is such a mental-emotional component with autoimmunity, we made sure to address this by finding sweetness in her life. We encouraged a gratitude journal, which brought her much joy. In addition, adding stress management techniques such as breath work and meditation were pertinent.

Results
She has improved drastically since starting at our clinic in October 2016. When she first started treatment with us, she walked with a cane and occasionally needed a walker. As treatment progressed, she walked without a cane, only using the cane twice during the treatment period for severe local inflammatory flare ups, with ultimately not needing a cane and walking extensively every day. Her recent labs, such as CRP and sedimentation rate, indicate less inflammatory cascades happening in her body. She reports 1/10 everyday pain and 2-3/10 pain occasionally when stressed, since it is a trigger for her. Patient has tapered off all medications with a conventional doctor, with only taking Tylenol PRN and Meloxicam as a backup when in pain. She also has less overall inflammation and pain to palpation. She is now able to swim for twenty minutes weekly, has gained more endurance overall, and recently has joined a sports league.